The Villas At Saratoga Skilled Nsg & Assisted Lvg

Based on interview and record review the facility failed to timely suspend two certified nurse assistants (CNA) who had an allegations of resident mistreatment in accordance with their abuse policy for two of two sampled residents (Residents 1 and 2). This failure had the potential to place residents at risk for further mistreatment should the allegation be proven.Findings:1.Review of Resident 1's Nurses Notes, dated 5/17/25 at 1:50 p.m., indicated the resident reported CNA A and told Resident 1 to shut up and mind your own business on 5/16/25. The same note indicated Resident 1 stated there were a few other times when the resident was verbally disrespected by the same CNA A and she felt belittled.During an interview on 7/2/25 at 12:29 p.m., the registered nurse (RN) B stated when she learned about Resident 1's allegation she did not suspend CNA A.2.Review of Resident 2's Nurse's Notes, dated 6/13/25 at 6:47 p.m. indicated the resident reported to therapy staff that she was punched and poked on the sides of her abdomen while being changed by CNA B when Resident 2 cannot urinate past…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to meet professional standards of care when staff did not intervene for a resident who was known to feed a roommate with swallowing problems (Residents 1 and 2). For Resident 3 she was not adequately monitored to prevent elopement and there was no policy addressing wander guard (alarm device such as a wrist band that sound when a person exits) maintenance and function for two of four sampled residents (Residents 1, 2 and 3). These failures placed residents at health and safety risk.Findings:1. Review of Resident 2's face sheet (document summarizing a resident's essential medical information) indicated she had diagnoses including dysphagia (difficulty swallowing food or liquid) and dementia (group of thinking and social symptoms that interferes with daily function). Her Minimum Data Set (MDS, an assessment tool, dated 4/18/25, indicated Resident 2 had severe problems with daily decision-making skills.Resident 2 had a physician's order, dated 6/5/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and document reviews, the facility failed to ensure overall dietetic services systems for food safety and sanitation were met, according to standards of practice and facility policy. This failure exposed the residents to contaminants (potentially harmful substances) in foods and unsanitary practices, which could have further compromised their nutritional status. The facility census was 84. Cross reference F802, F803, F804, F808, F812, and F908 Findings: During the initial kitchen tour on 12/16/24 starting at 9:07 A.M., multiple observations of unsanitary and unsafe equipment cleaning and food production practices in dietetic services were observed, including: the lack of kitchen cleanliness monitoring, lack of dish machine sanitizing monitoring, lack of recent kitchen staff food safety training, lack of kitchen staff following standardized recipes and therapeutic menus, and lack of an emergency menu for therapeutic diets. 1) Food Safety Storage and Production-Preparation: a. During the initial kitchen tour observation on 12/16/24 at 9:08…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not ensure food and nutrition services staff performed their job tasks competently according to standards of practice and facility policy when: 1. A Dietary Aide did not follow the recipe for puree salmon and a Diet Aide did not follow the recipe for tuna sandwiches. 2. A Dietary Aide did not properly test the sanitizing step of the high temperature dishwasher machine. 3. A Dietary Aide did not correctly demonstrate how to calibrate a food thermometer. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The facility census was 84. Cross reference F800, 803 Findings: 1. a) During a concurrent observation and interview on 12/16/24 at 9:45 a.m., a [NAME] K (CK K) was observed putting 5 scoops of bake salmon to blender machine, she added 2 cups of water using an aluminum measuring cup, then she blended it in a blender. After blending the pureed salmon, she acknowledged it was very watery. CK K…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

During observations, interviews, and record reviews, the facility did not ensure safe and sanitary practices were followed and maintained for food production and storage according to standards of practice and facility policy when: 1. An old dinner meal plate from the previous day was found inside the kitchen microwave the following day at 11:50 am. 2. Two dirty electric fans were inside the kitchen's food preparation and clean dish areas; 3. A cracked, dented, and worn aluminum measuring cup was used to make puree meals; These failures had the potential to impact the ability of dietary staff to prepare and serve coffee in a safe and sanitary manner. Facility census was 84. Cross reference F800, F802, F803 Findings: 1. During the initial kitchen tour observation on 12/16/24 at 9:30 a.m., a plate with a meat entrée resembling a pork chop, rice, broccoli, and a wheat dinner roll was found inside the microwave. During a follow up kitchen observation on 12/16/24 at 11:50 a.m., the meal plate was still inside the microwave. On 12/16/24 at 3:20 p.m., during an observation of the microwave,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure three of 4 residents (Residents 16, 62 and 84) had been informed about having an advance directive (AD, legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about AD and the Physician Orders for Life -Sustaining Treatment (POLST, a legal document stating the kinds of medical treatments patients want toward the end of their lives) was not completed and readily available in the event of a medical emergency. This failure had the potential to result in the inability to make medical decisions, and could lead to the delivery of unnecessary or inappropriate medical services. Findings: a. Review of Resident 16's face sheet (FC, a document that gives a resident's information at a quick glance) indicated, Resident 16 was admitted to facility on 7/8/15. Review of Resident 16's clinical record, indicated, there was no documentation of whether Resident 16 had an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their bed rail (adjustable rigid bars attached to the side of a bed) policy for 12 of 18 sampled residents (Residents 2, 4, 8, 16, 20, 23, 33, 43, 51, 67, 70 and 82). The facility failed to follow their bed rail policy for use of grab bars when: 1. For Resident #2 there was no physician order for the use of grab bars; 2. For Resident #43 and Resident 67 there was no physician order for the use of grab bars; 3. For Residents # 23, 33, 8, and 82, there were no care plans for the use of grab bars; 4. For Resident # 70, there was no physician order or care plan for the use of grab bars; 5. For Resident # 4, and 20 there was no physician order or care plan for the use of grab bars; 6. For Resident # 4, 16, 20, and 51 there were no care plans for the use of grab bars; These failures had the potential to compromise the residents' health and safety. Findings: 1. During an observation on 12/16/24 at 1:08 p.m., in Resident 2's room, Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility did not ensure standardized recipes for pureed meals and menus, which includes the emergency food supply were followed as printed, according to facility policy when: 1. A kitchen staff did not follow the facility's pureed diet lunch menu on 12/16/24 and 12/17/24. 2. A facility emergency menus unavailable These failures had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status for 77 residents consuming food from the kitchen. Cross reference 800, 802 Findings: 1.a) During a review of the facility's Winter Menus, Week 3-Monday 12/16/24, the lunch meal pureed diet includes Fish Fillet with Tarragon Sauce, Tartar Sauce, Cajun Country Rice, Creamed Spinach, Parsley Sprig Garnish, Sweet Corn Salad, and Fruit Bavarian Cream. During an observation on 12/16/24 at 1:02 p.m., with Resident 56, Resident 56 was observed eating her lunch meal in front of St. Catherine's nurse's station. Resident 56 had no puree spinach on her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility did not ensure the standardized recipes for the puree diet was followed as printed. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the nutritional status of twelve residents on puree diets. Cross reference F800 and F805 Findings: During a concurrent observation and interview on 12/16/24 at 9:45 a.m., a [NAME] K (CK K) was observed putting 5 scoops of bake salmon to blender machine, she added 2 cups of water using an aluminum measuring cup, then she blended it in a blender. After blending the pureed salmon, she acknowledged it was very watery. CK K then added 2 scoops of thickener to salmon mixture and started mixing it. CK K stated did not know how much water or thickener she added because there weren't any measurement numbers on the cup and scoop she used. CK K then stated she would add more thickener if needed to make it thick. During a review of recipe titled Pureed Meats there is a direction indicated, 1. Complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility did not ensure 21 residents receive their physician ordered therapeutic diet to meet their nutrition needs. This failure had the potential for to decrease nutrient intake and may have contribute to weight loss. Finding: According to a literature review of malnutrition, leading modifiable risk factors of malnutrition in Long-term care (LTC) include .poor nutrition .poor food/fluid intake .dependence on others for eating and impaired mobility. Additional .factors that lead to poor oral intake include poor food delivery systems . ([NAME], K.N.P., [NAME], S.R. & [NAME], C.W. Nutritional Vulnerability in Older Adults: A Continuum of Concerns. [NAME] Nutr Rep 4, 176-184 (2015). During a review of Facility Diet Order Tally Report-All Special Diets dated 12/16/24, indicated 21 residents were listed to receive a Fortified Diet (a Fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to treat three of 18 sampled residents (Residents 25, 45, and 64) with respect and dignity when: 1. The certified nurse assistant (CNA) stood beside the residents to assist with their meals, and 2. Resident 25's urine bag (bag that is attached to a tube that is connected to the bladder) was not covered. These failures resulted in not ensuring residents were treated with respect and dignity, and could potentially affect the residents' self-worth. Findings 1.During a dining observation on 12/16/24 at 12:37 a.m., the CNA G assisted Resident 45 with her meal. The CNA G was standing while trying to feed Resident 45. At 12:40 a.m., the CNA G assisted Resident 64 with her meal. The CNA G was standing while feeding Resident 64. During an interview with the CNA G on 12/16/24 at 2:01 p.m., the CNA G confirmed the above observations and stated she should sit down when providing assistance to residents during meals. During an interview with Licensed Vocational Nurse (LVN) H, on 12/16/24 at 2:05 p.m., the LVN H stated staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan for one of 18 sampled residents (Resident 20) to address the use of Clopidogrel (medication used to prevent blood clots). This failure had the potential to compromise the facility's ability to implement interventions to maintain the resident's well-being. Findings: Review of Resident 20's clinical record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease (or coronary heart disease, a condition that occurs when plaque builds up in the walls of arteries, making it difficult for blood to flow) of Native Coronary Artery without Angina Pectoris (chest pain or discomfort due to CHD), and drug induced Cushing's syndrome (a rare, chronic condition that occurs when the body produces too much cortisol [a hormone that helps the body respond to stress, maintain blood pressure , and regulate inflammation]). Review of Resident 20's Physician Order, dated 10/11/24 indicated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide care according to facility policy and procedure for one of 24 sampled residents (Resident 70) when a registered nurse (RN B) did not have the running of the continuous tube feeding (nutrition that is given through a tube that goes directly into the stomach) placed on hold when they put Resident 70's head of the bed flat to carry out a pressure ulcer treatment. This failure had the potential for enteral feeding complications that could cause harm to this resident. Findings: During a concurrent observation and interview on 12/19/24 at 6:51 AM, RN B placed Resident 70's head of the bed flat from its previous 30 degrees elevated position with tube feeding machine running the entire time. When asked about should be done with continuous tube feedings when putting the resident's head of the bed flat, RN B said, We hold the tube feeding. The feeding is paused. During an interview with the director of nursing (DON) on 12/19/24 at 11:29 AM, the DON said continuous tube feedings should be held when providing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dialysis (procedure to remove waste and excess fluid from the body) communication reports were complete (NDCRs) for one of 18 sampled residents (Resident 62). This failure had the potential to put Resident 62 at risk for complications. Findings: Review of Resident 62's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease (the kidney's no longer functioning on a permanent basis) and hypertensive (high blood pressure) chronic kidney disease with stage 5 chronic kidney disease. Resident 62's NDCRs dated 11/19/24, 11/23/24, and 12/12/24 were reviewed. The portion of the NDCRs to document Resident 62's post dry weight was left blank. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) H on 12/18/24 at 10:44 a.m., LVN H reviewed Resident 62's NDCRs dated 11/19/24, 11/23/24, and 12/12/24 and confirmed they were incomplete. LVN H stated the NDCRs should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to ensure accurate accountability of controlled drugs (those with high potential for abuse and addiction), when there were discrepancies between the controlled drug record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for 3 out of 6 residents (Residents 33, 9 and 28). This failure had the potential for abuse or misuse of controlled drugs. Findings: During the survey, the CDR (or count sheet) for six residents receiving PRN (as needed) controlled medications were requested for review. During an interview with the Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD) on 12/17/24 at 1:54 p.m., the ADON stated when a resident requests for a PRN (as needed) controlled medication, the nurse assesses the resident for pain severity; reviews the physician's order, and administers the medication if it's within the appropriate administration time to give the medication, removes the medication from the medication cart; signs it out of the count sheet; administers the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days for one of six sampled residents (Resident 2). This failure had the potential to result in the resident receiving the medication for an excessive length of time and experiencing adverse medication side effects. Findings: Review of Resident 2's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including dementia (decline in mental capacity affecting daily function), delusional disorders (mental health condition in which a person can't tell what's real from what's imagined), and major depressive disorder. Review of Resident 2's physician order dated 9/26/24 indicated Seroquel (antipsychotic medication that calms the mind and reduces anxiety) 25 milligrams (mg, unit of dose measurement). Give 12.5 mg by mouth every 12 hours as needed for psychosis (a mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility had a medication error rate of 8.82% when three medication errors occurred out of 34 opportunities during the medication administration for two of four residents (Residents 18 and 89). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications or adverse effects, compromising their health. Findings: 1. During a medication administration observation on 12/16/24 at 9:14 a.m. with Registered Nurse (RN) C, RN C was observed preparing twenty medications for Resident 89 including an Arnuity Ellipta inhaler (medication used to treat the symptoms of asthma (an inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath). On 12/16/24 at 9:35 a.m., at the bedside of Resident 89, RN C gave the Arnuity Ellipta inhaler to the resident. Resident 89 self-administered two puffs of the oral inhaler simultaneously one after another.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper infection control practices were implemented when: 1. Staff failed to ensure the dirty linen container was fully covered by having dirty linen sticking out of the container; 2. Staff failed to ensure a continuous positive airway pressure machine (CPAP, machine used to treat sleep apnea [a condition where breathing repeatedly stops and starts during sleep]) mask and hose were properly disinfected; 3. Staff failed to label two urinals found in a shared resident bathroom with resident identifier; 4. During a treatment, a registered nurse (RN) grabbed multiple items with gloved hands without changing the gloves, 5. One licensed vocational nurse(LVN) did not disinfect the glucometer in between blood sugar level checks. These failures had the potential to compromise residents' health and safety in the facility. Findings: 1. During an observation and concurrent interview with Certified Nurse Assistant (CNA) G on 12/16/24 at 11:25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not ensure a coffee machine was maintained in a safe operable condition according to manufacturer's guidelines and facility policy. This failure had the potential to impact the ability of dietary staff to prepare and serve coffee in a safe and sanitary manner. Facility census was 84. Cross reference F800 Findings: During an observation of the lunch trayline meal service on 12/16/24 and 12/17/24, the Diet Aide N (DA N) was observed preparing coffee for the resident meals using the coffee machine. DA N prepared 78 cups of coffee on 12/16/24 and 77 cups of coffee on 12/17/24 during each of the lunch meal services. During a concurrent observation and interview on 12/17/24 at 9:50 a.m., with the Foodservices Director (FSD), the FSD confirmed the coffee machine had three missing buttons, electrical wires exposed inside each button space, and a clear strip of tape securing the coffee machine's door. The FSD stated the coffee machine had these issues for several months but the facility was on a wait list to get a different…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when: 1. Food storage containers were wet, and with white stains in kitchen storage cabinets; 2. Utensil storage drawer had brown dried particles; 3. Food blender black gasket with brown dried particles; 4. [NAME] cutting board with stained and scratches; 5. Tip of can opener blade with small black substance; and 6. Ice scooper was placed close to a soap dispenser. These failures had the potential to result in food borne illness among residents. Findings: 1. During an initial kitchen tour with the kitchen supervisor (KS) on 11/7/22 at 8:45 a.m., noted one eight quarts (unit of measurement) plastic food storage container was wet with water droplets and white stains. This container was stacked on top of five other wet containers in one of the kitchen cabinet. Nine other four quarts plastic food storage containers, and two lids were stacked wet with water droplets, in another kitchen cabinet. The KS confirmed those containers, and lids…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. The facility did not implement COVID-19 (a highly contagious respiratory disease) screening protocol; 2. Staff did not perform hand hygiene in between tasks; 3. Clean linen room had debris, dust, loose off-white particles and black matter stuck to the floor; 4. Soiled linen bin with dirty linens in it was left opened in the hallway; 5. Resident's used surgical mask was left hanging on a wheelchair handle; 6. A used mask was left on the screening table; 7. The treatment nurse (TN) did not perform hand hygiene in between task; and 8. Staff did not wear gloves in handling soiled linen. These failures could result in the spread of infection and cross-contamination that could affect the 86 residents who resides in the facility. Findings: 1a. During an observation on 11/7/22 at 8:00 a.m., there were no instruction what personal protective equipment (PPE, equipment worn to minimize exposure to hazards) needs to be worn or if screening was required before…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignity and respect was provided for one of three residents (Resident 6) when staff did not assist Resident 6 during lunch while other residents at the same table were already eating. This deficient practice violated the resident's right to be treated with dignity. Findings: During a dining observation on 11/7/22 at 12:17 p.m., Resident 6 was sitting in the dining room, tapping the table with his right hand and was waiting for staff to assist him with lunch. Another resident (Resident 13) at the same table was already eating. During a concurrent observation and interview with Licensed Vocational Nurse a (LVN A) on 11/07/22 at 12:24 p.m., LVN A confirmed the above observation and confirmed Resident 6 needed staff assistance with eating and Resident 6 should have been attended to. During an interview with the Director of Nursing (DON) on 11/14/22 at 11:17 a.m., she stated all residents' needs should be attended to and all residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to assess if the resident was safe to self-administer medications for one of 20 sampled residents (Resident 49). This failure had the potential to result in unsafe medication administration and could have allowed other residents to access unlocked medications. Findings: During a concurrent observation and interview on 11/10/22 9:42 a.m., in Resident 49's room, observed resident handed a Combivent 20-100 inhaler (medication to treat and prevent wheezing and shortness of breath caused by ongoing lung diseases) to Licensed Vocational Nurse (LVN) C. Resident 49 stated the inhaler was left on her over bed table the night before. During an interview on 11/10/22 9:50 a.m., with LVN C, she confirmed above observation, and stated the inhaler should have been collected by the nurse right after administration. During an interview on 11/10/22 10/45 a.m., with the Director of Staff Development (DSD), she stated licensed nurse should have taken the inhaler back after administration and stored it in the medication cart. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure time change was communicated to one of 18 resident (Resident 52) when Resident 52 was not aware the day light saving time (DST) ended. This failure had the potential to result in resident needs not being met. Findings: During an interview with Resident 52 on 11/7/22 at 12:47 p.m., Resident 52 stated she was not aware there was a time change. Resident 52 further stated she was not happy the facility did not announce the time change and was hungry. During a concurrent observation in Resident 52's room, there was a calendar of activities posted Resident 52's room but did not indicate an information regarding time change. During an interview with the activity director (AD) 11/9/22 at 8:38 a.m., the AD stated he announced the change of time last week during a mass and bingo game. The AD confirmed Resident 52 was not part of the mass or bingo game. The AD further acknowledged he was not able to update some resident's calendar. Review of the facility's policy, Accommodation of Needs, revised March 2021…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure three of 18 residents (Residents 32, 138, and 139) were made aware of an advance directive. This failure had the potential of leaving residents not having a way for their health care wishes to be followed, by a selected representative, if they become incapacitated. Findings: 1. During a review of Resident 32's medical record (record), record indicated, documentation of whether Resident 32 had an advance directive was not located. During an interview with licensed vocational nurse N (LVN N) on 11/09/22 at 3:30 p.m., LVN N stated, she helps with admissions, but was not sure if she helped with Resident 32's admission and advance directives. LVN N stated, once the Physician Orders for Life-Sustaining Treatment (POLST) form is filled out, we put the POLST form in the doctors binder for them to sign. During a review of Resident 32's POLST, dated 10/27/22, the POLST indicated, no boxes were checked for: having an Advance Directive, Advance Directive not available, or No Advance Directive. During an interview with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to notify the resident or their representative in writing and the office of the long-term care ombudsman (ombudsman) for two of three residents (Residents 32 and 76) when transferred to a general acute care hospital (GACH). This failure had the potential of residents being transferred wrongfully. Findings: During a review of Resident 32's medical record (record), record indicated she had been transferred to GACH five times. There was no indication of Resident 32, her representative, nor ombudsman had been notified of her transfer for any of the five transfers. During a review of Residents 76's medical record (record), record indicated she had been transferred to GACH once. There was no indication of Resident 76, her representative, nor ombudsman had been notified of her transfer to GACH. During an interview with the medical records (MR) on 11/10/22 at 1:28 p.m., the MR stated, if there is an unplanned discharge to GACH, nursing notifies ombudsman; if the discharge is planned, social services notifies ombudsman. The MR stated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to notify two of three residents (Residents 32 and 76) or their representatives of the facility's bed hold policy when they were transferred to a general acute care hospital (GACH). This failure had the potential of residents not being allowed to return to the facility. Findings: During a review of Resident 32's medical record (record), record indicated she had been transferred to GACH five times. During a review of Residents 76's medical record (record), record indicated she had been transferred to GACH once. During an interview with the social services coordinator (SSC), on 11/10/22 at 1:31 p.m., the SSC stated, the nurse will ask the responsible party if they want a bed hold. A form is filled out and faxed to the ombudsman by social services. During an interview with the medical records (MR) on 11/14/22 at 11:11 a.m., the MR stated, she had brought SSC to surveyors and SSC had said they had not been filling out bed hold forms, so we don't have anything. Nothing for residents, representatives, or ombudsman, from either…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Minimum Data Set (MDS, a resident's clinical assessment) Significant Change in Status Assessment (SCSA - a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their residents) has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 21 residents after Resident 88 had a worsened pressure ulcer and a significant weight loss (weight loss of five percent or more in the last month, or ten percent or more in the last six months). This failure had the potential to negatively affect the planning of care and provision of appropriate services for this resident. Findings: A review of Resident 88's clinical record indicated, she was admitted on [DATE] with diagnosis of urinary tract infection, COVID-19 (an infectious disease caused by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR, screening for individuals with a mental disorder and individuals with intellectual disability) screening document was accurately completed for one of 18 residents (Resident 50). This failure had the potential for mentally ill residents not to receive the required care and services. Findings: Review of Resident 50's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including unspecified psychosis (a severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality). During a concurrent interview and record review with the minimum data set coordinator (MDSC) on 11/9/22 at 3:18 p.m., the MDSC reviewed Resident 50's PASRR and confirmed the question regarding mental disorder was answered No. The MDSC further stated the answer should be yes. According to PASRR Facility Training Update 111221 (ca.gov) website, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensue services provided meet professional standards for two of 20 sampled residents (Resident 14 and 48) when: 1. One nursing staff did not follow the physician's order for administering as needed Morphine (a controlled medication for moderate to severe pain) 2. One nursing staff did not use two identifiers to identify a resident prior medication administration. These failures had the potential for medication administration error (given a wrong dose) and administer a medication to a wrong resident. Findings: 1. During a medication administration observation on 11/7/22, at 11:38 a.m., Licensed Vocational Nurse (LVN) B drew 0.5 milliliter (ml, unit of measurement) of Morphine Sulfate solution 20 milligram (mg, unit of weight)/ml from a newly opened bottle using a syringe for Resident 48. A review of Resident 48's physician's order, indicated resident's Morphine order was: Morphine Sulfate (Concentrate) Solution 20 MG/ML give 0.25 ml sublingually every 4 hours as needed for moderate to severe pain/ SOB, start…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure necessary care and grooming services were provided for two of two residents (Resident 15 and Resident 18) when Residents 15 and 18's fingernails were long, had yellow and black particles, and were not trimmed. This failure had the potential to affect the residents' care and well-being. Findings: Review of Resident 15's clinical record, indicated she was admitted on [DATE] with diagnoses including lack of coordination and weakness. During a concurrent observation and interview with the treatment nurse (TN) on 11/7/22 at 9:54 a.m., inside Resident 15's room. Resident 15's fingernails were long, were yellowish in color and were not trimmed. The TN stated the fingernails should have been trimmed and kept clean and short. During an interview with certified nursing assistant Q (CNA Q) on 11/7/22 at 11:20 a.m., CNA Q stated CNAs were responsible in clipping residents' fingernails. During a concurrent interview and record review with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure two of 18 sampled residents (Resident 6 and 50) received the necessary care, and services when: 1. Resident 6's wound assessment was not done; and 2. Resident 50's care plan intervention for the use of thrombo-embolic deterrent (TED, specialized stockings to help prevent leg swelling and blood clots) hose was not implemented. These failures had the potential to affect the resident's care, health, and well-being. Findings: Review of Resident 6's clinical record indicated he was admitted with need for assistance with personal care, reduced mobility, hemiparesis (inability to move one side of the body). Review of Resident 6's Minimum Data Set (MDS, a standardized assessment tool), dated 8/11/22, indicated his cognition was impaired. During an observation on 11/8/22 at 8:48 a.m., inside Resident 6's room, a band aid (dressing to cover wounds) was observed on his left hand. During a follow up observation with the Treatment Nurse (TN) on 11/9/22 at 2:34 p.m., in the activity room. Resident 6's wound on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services to prevent pressure injury for one of three residents (Resident 51) when white cream was applied to Resident 51's coccyx (tail bone) area not consistent to the physician order. This failure had the potential to cause of worsen pressure ulcers. Findings: Review of Resident 51's clinical record indicated he was re-admitted to the facility on [DATE] with diagnoses including pressure injury on the sacral region (coccyx). During a wound treatment observation in Resident 51's room on 11/14/22 at 10:19 a.m., Resident 51 coccyx area had a white cream. The TN then used gauze with normal saline to wipe out the white cream. During an interview with the TN on 10:32 a.m., the TN stated barrier cream should not cover Resident 51's wound bed. Review of Resident 51's physician order did not indicate any cream treatment on his coccyx. During an interview with the minimum data set coordinator MDSC) on 11/14/22 at 11:25 a.m., the MDSC stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure three of five sampled residents, (Resident 24, 64 and 2) were free from unnecessary psychotropic medications (medication capable of affecting the mind, emotions and behavior) when: 1. For Resident 24, failed to identify and monitor the specific target behavior for the use of quetiapine fumarate (Seroquel, medication use to treat certain mental/mood conditions such as schizophrenia [severe mental disorder affecting how a person's think, feel and behaves]) 2. For Resident 64, the facility failed to ensure there was a specific duration of use for PRN (PRN, as needed) psychotropic medication that exceed 14 days for the use of Lorazepam (medication for anxiety [persistent feeling of worry and fears]); 3. For Resident 2, the facility failed to monitor a specific behavior for the use of Seroquel. These failures could result in lack of adequate monitoring and had the potential for residents to receive unnecessary medications. Findings: 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when an insulin (medication to treat high blood sugar) pen had the pharmacy label on the cap instead of the body of the pen. This deficient practice had a potential to result in medication errors due to medications not being labeled and stored appropriately. Findings: On 11/14/22 1:26 p.m., the inspection of Medication Cart #1 with the Director of Staff Development (DSD), identified one insulin pens which had the pharmacy label on the cap instead of on the body of the pen. During a telephone interview with the Consultant Pharmacist (CP) on 11/14/22 at 1:48 p.m., he stated that it was advisable to put the pharmacy label on the body of the pen, not on the cap, to prevent mix-up errors. A review of the 2017 Institute for Safe Medication Practices' (ISMP, a nonprofit patient safety organization with recognized national expertise in medication error prevention) Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults, it indicated, A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide physician prescribed thickened liquid for one out of one sampled resident (Resident 51). This failure put Resident 51 at risk for aspiration (food or liquid going into the lungs) that could compromise his health condition, and well-being. Findings: Review of Resident 51's clinical record indicated, Resident 51 had a diagnosis of cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain cells to die off), and dysphagia (difficulty swallowing food or liquids). Review of Resident 51's physician order, dated 10/20/22, indicated pureed (cooked foods blended to the consistency of pudding or baby food so little or no chewing is necessary) texture diet and nectar thick liquids (liquids thicker than water, mildly thickened liquids to help those with difficulty swallowing regular consistency liquids). An observation during lunch in Resident 51's room on 11/10/22 at 12:22 p.m., noted certified nursing assistant O (CNA O) fed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure one of two garbage disposal dumpster container lid was closed. This failure had the potential for harborage and feeding of pests. Findings: During facility's garbage disposal site inspection with the kitchen supervisor (KS) on 11/8/22, at 9:45 a.m., noted one garbage disposal dumpster container, and one recycle disposal dumpster container inside gated area located outside by the facility's parking lot, behind the kitchen. Observed garbage disposal dumpster container with bag of trash inside, and one of the lid was open. The KS stated lid was left open, and the KS closed the lid. During an interview with the KS on 11/8/22, at 9:45 a.m., the KS stated lid should be closed all the times to prevent pest problem. During an interview with registered dietitian J (RD J) on 11/9/22, at 9:49 a.m., RD J stated garbage disposal dumpster lid should always be closed. Review of the facility's policy and procedure titled Miscellaneous areas dated 2020, Indicated Garbage and trash cans must be inspected daily that no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent (%), as evidenced by the identification of eight medication errors out of 29 opportunities, to yield a facility medication error rate of 27.59%: 1. For Resident 188, four medications were not given. 2. For Resident 67, the physician's order was not followed. 3. For Resident 26, three medication dosages were not fully given as prescribed. These failures had the potential to compromise the residents' medical health and safety. Findings: 1. For Resident 188, four medications were not given. During a review of Resident 188's admission Records dated 1/17/2020, indicated Resident 188 was admitted on [DATE] with diagnoses of epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat), hypertension (high blood pressure) and presence of cardiac pacemaker (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to follow policy and procedure related to medication storage when: 1. Three out of four nursing station refrigerators were not being monitored accordingly when storing vaccines. 2. Expired Medications 3. Two licensed nurses left medication unattended. These deficient practices put resident's health and safety at risk. Findings: 1. Three out of four nursing station refrigerators were not being monitored accordingly when storing vaccines. During an observation at station one's medication refrigerator with the assistant director of nursing (ADON) on 1/14/2020 at 3:04 p.m., the ADON confirmed Afluria (flu vaccine) was stored inside the refrigerator while the facility staff was only monitoring temperature once a day. During an observation at station two's medication refrigerator with the ADON on 1/14/2020 at 3:25 p.m., the ADON confirmed two Afluria and one Prevnar (vaccine used to prevent infection caused by pneumococcal bacteria) was stored inside the refrigerator while the facility staff was only monitoring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for two of 18 sampled residents (Residents 41 and 59) and in two of two hallways. This failure resulted in the residents' discomfort and had the potential for all residents to be uncomfortable in the hallways. Findings: 1. During a concurrent observation and interview on 1/14/2020 at 2:45 p.m., Certified Nursing Assistant (CNA) A was at Resident 59's bedside, and Resident 59 stated she was cold. During a concurrent observation and interview on 1/15/2020 at 2:10 p.m. with the Director of Maintenance (DOM), in Nursing Station (NS) A, the DOM was observed using the temperature gun to check the temperature in Resident 59's room. The temperature gun readings indicated a range of 69 to 81 degrees Fahrenheit. During a concurrent observation and interview on 1/16/2020 at 1:33 p.m. with the DOM, in NS A and NS B, the DOM was observed using the temperature gun to check the hallway temperatures and the readings were 69 degrees Fahrenheit in each hallway. During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer medications as prescribed for two of seven sampled residents (Residents 59 and 134) when: 1. For Resident 59, the licensed nurse did not administer the prescribed PRN (as needed) cough medicine when the resident was coughing. 2. For Resident 134, the licensed nurse did not administer the prescribed PRN pain medications for the pain levels indicated on the physician's orders. This failure had the potential to cause discomfort and delay treatment for the residents. 1. During an observation and interview on 1/14/2020 at 2:45 p.m., Resident 59 was observed, in bed, with a wet cough (a type of cough that results from the mucus in the airways). Resident 59 stated she wasn't getting medicine for the cough. During a record review of Resident 59's Physicians Orders, dated 1/3/2020, the orders indicated to administer Geri-Tussin Syrup (guaifenesin) (cough medicine used to reduce chest congestion by breaking up mucus so it can be coughed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide communication tools and services for two out of three residents (10 and 26) with communication barriers when: 1. For Resident 10, the facility staff were unable to establish communication and did not implement the use of a communication board (A communication tool that includes words, phrases, and/or pictures in a foreign language and English used to facilitate communication for people with language barriers) as indicated in the care plan. 2. For Resident 26, the facility did not ensure that communication can always be established through a translator, as indicated in the care plan, or other tool, in the absence of a translator. These failures resulted in Resident 10's frustration and had the potential to impact both residents' abilities to communicate their needs and delay treatment. Findings: 1. During a review of Resident 10's Physician's Progress Note, dated 6/15/19, the note indicated Unable to talk to patient. No translator available .Please call our office to R/S [reschedule]. During a record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of 18 Residents (44) received care and services by failing to provide medication as prescribed. This failure put Resident 44's health and safety at risk. Findings: During a review of Resident 44's admission Record, dated 1/16/2020, the admission Record indicated Resident 44 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses of anemia, gastro-esophageal reflux disease (GERD, occurs when stomach acid frequently flows back into the tube (esophagus) connecting mouth and stomach), nonrheumatic aortic valve stenosis (narrowing of the heart's valve), chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness ) and acute on chronic diastolic (congestive) heart failure (is a condition when the heart is not able to fill properly with blood, reducing the amount of blood pumped in the body). During a review of Resident 44's General Acute Care's Discharge -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview record reviews the facility failed to follow pharmacy services policies and procedure when: 1. For Resident 188, new medication orders were not delivered on a timely manner. 2. For Residents 134 and Resident 31, the facility failed to ensure accurate or effective accountability of controlled substances (drugs with high potential for abuse or addiction). 3. Nurse's station one had two of the same emergency kits. These failures caused delayed in treatment and potential to put resident's health and safety at risk. Findings: 1. For Resident 188, new medication orders were not delivered on a timely manner. During an interview on 1/13/2020 at 10:30 a.m., Resident 188's family member stated Resident 188 was admitted on [DATE] but the facility nurses were still not able to administer morning medications. During an interview on 1/13/2020 at 10:33 a.m. with licensed vocational nurse A (LVN A), LVN A confirmed that four medications were still not delivered from the pharmacy for Resident 188.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of 18 sampled residents (4) were free from unnecessary psychotropic drugs (any drug that affects brain activity) when psychiatry recommendations were not acted on timely manner. This deficient practice had the potential to put residents at risk to receive unnecessary psychotropic medications. Findings: During a review of Resident 4's admission records, dated 1/16/2020, indicated Resident 4 was admitted on [DATE], started hospice care on 4/11/19, with diagnoses of malignant neoplasm (cancerous tumor) of pancreas and prostate, psychosis (a mental disorder in which thought and emotions are so impaired that contact is lost with external reality), dementia (problems with memory and thinking) and high blood pressure. During a review of Resident 4's physician's order, dated 8/20/19, indicated Seroquel (an anti-psychotic medication used to treat certain mood and mental conditions) 100 mg (milligram, a unit of measurement) twice a day for psychosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.